Hazard Alert Form

Please provide as much contact information as you believe is necessary:

Campus/Facility: Date:

Imminent hazards posing an immediate danger to life and health should be reported immediately to the EHS office (x84728) or your supervisor.

Location of Hazard (incl. building and room #):

Description of Hazard:

Recommendation for Correction:

Has this hazard been reported to your supervisor? (Yes/No)

OPTIONAL

Employee First Name:
Employee Last Name:
Department:
Telephone:

Note: It is illegal for any California employer to take action against employees who exercise their right under law to report unsafe conditions.

Your feedback will be processed as soon as possible. Some requests may need to be forwarded to specific individuals elsewhere within this organization.